When to stop colonoscopy surveillance in the elderly?

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In the article by Puylaert et al. in this issue of the Netherlands Journal of Medicine, adherence to surveillance guidelines for colorectal adenomatous polyps in the elderly was assessed. In this retrospective study the authors presented data on the adherence to surveillance guidelines after polypectomy and gastroenterologists’ recommendations, and on the other hand the actual surveillance that was practised in elderly patients. They found that in 41% of the cases the recommendation of the gastroenterologist was not in accordance to the guideline, but reasons for deviation were foremost unknown. As the authors stated, timely surveillance is importantAs the authors stated, timely surveillance is important but timely cessation is just as relevant, especially in the elderly. Although age is associated with an increased risk of adenoma and colorectal cancer development, this risk may be lower when patients are already under surveillance and have undergone (repeated) colonoscopies, especially in the elderly,1,2 while the risk of colonoscopy-related complications is increased in this group of patients.3 The increasing age of patients and the start of the national colorectal screening program is resulting in a growing number of surveillance colonoscopies, making this a more common dilemma which we will increasingly encounter in daily practice. The fact that they found that in around 40% of the elderly patients recommendations were not in accordance to the guideline may be an indication that guidance in selecting the right older patients to undergo surveillance colonoscopy is lacking. However, this should be interpreted with caution because the data are from one single centre. The current Dutch guideline recommendations on surveillance after polypectomy are based on polyp characteristics, location of polyp, age and gender. However, clear recommendations on when to stop surveillance are still lacking. Also tools to assess the frailty / vitality of the patient in order to evaluate the clinical relevance of performing a surveillance colonoscopy versus the risk of complications in an individual elderly patient are absent. This lack in guidance and tools to assess a more individual benefit-harm risk profile for the elderly is probably reflected in the 40% non-adherence to guidelines. As advised by the authors, a decision algorithm to support cessation of surveillance colonoscopies for elderly patients but maybe for all ages will help to give guidance for daily practice and will result in a more uniform approach providing surveillance colonoscopies for those who benefit the most.